1. Introduction
We invite you to participate in the DSHS Farm to Work Survey. This survey is designed especially for employees of the Texas Department of State Health Services. Your responses will assist us in the development and improvement of wellness programs at your worksite including Farm to Work
(for more information on Farm to Work, visit: {insert url}.
This survey should take 5 to 10 minutes to complete. All of your answers are confidential and your name will not be associated with the answers that you give. Your survey will be given a code number and your identifying information including your name will be separated from your answers after the data have been entered. Your completion of this survey implies your consent to take part in this survey evaluation.
You are making the decision whether or not to participate in filling out this survey. You may withdraw at any time should you choose to discontinue your participation. Your decision to begin or continue participation in completing this survey will in no way affect your job DSHS.
You will need to complete the entire survey at one time. While you are in the survey you will be allowed to go back if you would like to change or add to your answer. Once you exit the survey your responses will be tabulated immediately. You cannot go and finish the survey at a later time. 1. Please fill in your name and work information. This information will not be used to
identify you or your answers.
Last name: ____________________________ First name: ____________________________ _ Work e-mail address: _____________________________________________________________ Employee ID number: _____________________________________________________________ 2. At what DSHS location do you currently work?
Your worksite ______________________________________________________ (DSHS location) 2. Fruit and Vegetable Intake
These questions are about the foods you usually eat or drink. Please indicate how often you eat or drink each one, for example, twice per week, three times per month, and so forth. Include all the foods you eat, both at home and away from home. These questions are meant to capture all forms of fruits and vegetables including fresh, frozen, and canned. Please give just one response per question. 1. How often do you drink fruit juices such as orange, grapefruit, or tomato?
(Please indicate the number of times per day, week, month, OR year.)
Times per day Times per month Never
Times per week Times per year
2. Not counting juice, how often do you eat fruit?
Times per day Times per month Never
Times per week Times per year
3. How often do you eat green salad?
Times per day Times per month Never
Times per week Times per year
4. How often do you eat potatoes not including French fries, fried potatoes or potato chips?
Times per day Times per month Never
36 Evaluation Tools–Employee Survey 5. How often do you eat carrots?
Times per day Times per month Never
Times per week Times per year
6. Not counting carrots, potatoes or salad, how many servings of vegetables do you usually eat? (Example: A serving of vegetables at both lunch and dinner would be two servings.)
Times per day Times per month Never
Times per week Times per year
3. Source of Meals
The following questions ask about where your meals typically come from. Please indicate how often you think you engage in these behaviors in a typical week. Please give just one response per question.
1. In an average week (including the work week and weekend), how many mornings do you eat breakfast that was prepared in your home?
Mornings per week
2. In an average work week, how many times do you pack a lunch from home to bring to work? Times per work week
3. In an average week (including the work week and weekend), how many nights do you eat dinner that was prepared in your home?
Nights per week 4. Food Environment
The next questions address different aspects of eating, food, and the environment at your worksite. Strongly Disagree Somewhat Disagree Not Sure Somewhat Agree Strongly Agree
In the last month, I have tried at least two kinds of fruits or vegetables that I had never eaten before.
I do not generally eat a wide variety of produce. My fruit and vegetable choices generally include many different colors.
My coworkers are not supportive of my eating fruits and vegetables.
The place I work makes it easy for me to eat more produce.
On average, I would say that the produce I currently eat has high quality taste and flavor.
On average, most of the produce I eat is grown locally. I have a great sense of pride and loyalty to the place I work.
37 Evaluation Tools–Employee Survey
DSHS Employee Online Survey
Please read each statement and determine how much you agree or disagree with each. 5. Food Buying and Preparation
These questions address different aspects of food buying and preparation. These questions are meant to capture the habits of your household, so please answer the questions with the habits of your household in mind. (For example, if your spouse does most of the food shopping, try to answer questions about purchasing from his/her perspective.)
Please read each statement and determine how much you agree or disagree with each.
Strongly Disagree Somewhat Disagree Not Sure Somewhat Agree Strongly Agree
In the last month, I have used new recipes and/or preparation methods to prepare dishes that include produce.
I do not know where the produce I usually purchase/ eat is grown.
Knowing where the produce I purchase is grown is an important factor in my decision to purchase/eat it. The time it takes for me to purchase and transport the produce I eat is burdensome to me.
When it comes to buying produce, I have many fresh fruits and vegetables available to me that are convenient to purchase.
6. Thank You
Thank you for taking the time to complete this survey. We value your feedback. If you have any further questions about this survey, please contact:
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